11/12/2021 Septic Compliance Inspection

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1580 County Rd 6 (6th Ave N�_ _ Parcel ID: 2611823320006 Property address: � City; Orono State: MN __ Zip code:. 55356 -_ Optional section: Sewage Tank Compliance Certification (Tank integrity assessment) This form does not represent a complete system inspection report and only certifies sewage tank compliance status. i.e., this form, completed, may serve as a tank integrity assessment, rtified Instructions: B Business who personally ally conducts thcompleted pecessary roceduresgned by a Dt a'ssessdtheecompl individual statusDofilicensed each s Maintenance sewage tank In the system. When this section of the form is signed by a qualified certified professional, it becomes necessary supporting documentation to an Existing System Compliance Inspection Report: n form Existing system (wa-+srwists4-31b1. This form can be found on the MPCA website at https:/hvww.pca.state.mn.ustwateriservice-and-maintenance. The Information and certified statement on this form is required when existing septic tank compliance status is determined by an individual other than the SSTS Inspector that submits an inspection report, This form represents a third party assessment of SETS component compliance and is allowable under Minn. R. 7082.0700, subp. 4 Item (B) subitem (1). This form is valid for a period of three years beyond the signature date on this form unless a new evaluation Is requested by the owner or owner's agent or is required according to local regulations. Additional Administrative Rule references for this activity can be found at Minn. R_ 7nfi2.n700. subp. 4 hems B, C, and D; 7083.0730 Item C. ® Certificate of sewage tank compliance Affirm all three statements: The SSTS does not contain a seepage pit, cesspool, drywall, leaching pit, or other pit. ® It does not contain a sewage tank that was designed to be watertight, but subsequently leaks below the designed operating depth. $J It does not represent an imminent safety threat by reason of unsecured, damaged, or weak maintenance hole cover(s) or other unsafe condition. ❑ Notice of sewage tank non-compliance Select all that apply: ❑ The SSTS has a seepage pit, cesspool, drywall, leaching pit, or other pit — "Failure to Protect Groundwater." ❑ It has a sewage tank that was designed to be watertight, but subsequently leaks below the designed operating depth —'Failure to Protect Groundwater." ® It presents a threat to public safety by reason of unsecured, damaged, or weak maintenance hole cover(s) or other unsafe condition — "Imminent Threat to Public Health or Safety." Company information Designated Certified Individual (DCI) Information Company name: Albin's Septic Pumping, LLC-.._-". Print Warne: „Peter Peterson_ Business license number: 3346 _ Certification number: 9227 I personally conducted the work described above as a Designated Certified Individual of a Minnesota -licensed SSTS Maintenance Business. t personally conducted the necessary procedures to assess the compliance status of each sewage tank in this SSTS. By typing/signing my name below, I certify the above stat encs to be true and correct, to the best of my knowledge, and that this Information can be used for the purpose of pro i.. form. Designated Certified individual's signature: Date (mmlddtyyyy):_ 11 /12/2021_ _ "-- www.pea.state.mmus • 651-296-6300 • 800-657-3864 • Use your preferred relay service Available in alternative formats Page 3 02 wq-ww1sts4-38 • 1/7/21